In essence, the name tension headache is incorrect since it suggests that it is related to stress, which is seldom the case.

Tension headache is the most frequent form of headache and is the collective name for various forms of headache not otherwise classified. Tension headache is divided into episodic (less than 15 days per month) and chronic (more than 15 days per month) forms, depending on the duration of symptoms.


Up until now, the exact cause of tension headache is unknown, but is probably multi-factorial, with hypersensitivity to pain playing an important role. Hereditary factors appear to play a role in chronic daily headaches. Moreover, a relationship with (psychological) stress, poor posture, overuse of painkillers, and fatigue can also be seen. Tension headache may also occur from no obvious cause.

Signs and symptoms


Tension headache typically presents as a bilateral, tightening and oppressive headache (band feeling). Only in a minority of cases is there increased muscle tone in the neck and shoulder region. The pain is less severe than in, for example, migraine; daily functioning is usually not hindered. Accompanying symptoms such as nausea or photophobia, phonophobia, and worsening as a result of exertion, are not seen in patients with tension headache.


Physical Examination

Patients with tension headache do not present with any abnormalities on neurological examination.

Additional Somatic Diagnostics

The tension headache diagnosis is carried out based on the patient's medical history and when the headache does not comply with other diagnoses, such as, migraine or cluster headache. A headache diary can help in making the diagnosis. Additional examinations, blood tests or imaging techniques for other causes of the headache, are not usually necessary.

Additional Psycho-cognitive Diagnostics

  • RAND-36 (quality of life)
  • VAS-Pain (maximal, minimal, actual, average/week)
  • PCS (catastrophising)
  • HADS (fear and depression)

Multidisciplinary Treatment

Whether or not somatic treatment is indicated is based on the pain diagnosis.  Based on the findings of the pain questionnaires, additional diagnostics and/or multidisciplinary treatment comprising various non-somatic treatments may be necessary.

Non-somatic Treatment

Somatic Treatment

Pharmacological treatment:

  • Tension headache is a heterogeneous disease. Therefore, a single type of treatment will not be effective in all patients.
  • A distinction must be made between the episodic and chronic variants.
  • Caution is advised regarding the use of painkillers, since these can in themselves cause headache.
  • If the over-use of painkillers is thought to play a role, these must first be stopped.
  • Drugs for migraine and cluster headache are not effective.

Episodic variant

  • Avoid provoking factors
  • Avoid over-use of painkillers

Chronic variant

  • As in the episodic variant
  • Amitriptyline


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